Senators Seek Direction on Combating Opioid Abuse

Caps on buprenorphine prescribing a point of controversy

WASHINGTON -- Over and over again on Tuesday, members of the Senate Health, Education, Labor, and Pensions (HELP) Committee kept asking witnesses what Congress could do to help them combat opioid abuse.

"What would your suggestions be for getting some degree of commonality and some better coordination between different states' prescription drug monitoring programs (PDMPs)?" asked Sen. Sheldon Whitehouse (D-R.I.).

"If we at the federal level [granted] the Department of Veterans Affairs access [to a state's PDMP database] that be something tangibly we could do to benefit those patients -- fair statement?" asked Sen. Bill Cassidy, MD (R-La.).

"We have certainly seen a real campaign for a crackdown on overprescribing," said Sen. Tim Scott (R-S.C.). "How do we on the front end prevent this rising challenge from occurring in first place? Are there key signs or things we can do to help prevent it on the front end?"

The HELP committee hearing on examining solutions to the opioid abuse problem encompassed a wide variety of issues. Committee chair Lamar Alexander (R-Tenn.) noted that during a roundtable discussion in Knoxville, Tenn., state representative Bill Dunn (R-16) "told me that the patient satisfaction survey from Medicare patients has the perverse effect of encouraging physicians to overprescribe painkillers, because reimbursements to hospitals are based to some extent on the score patients give their doctors on how well-satisfied they are with treatment."

Alexander said he had discussed the issue with Health and Human Services Secretary Sylvia Burwell, and added that "President Obama ... [has] announced his willingness to review the patient satisfaction survey. I was glad to see this response from the [Obama] administration."

Sen. Susan Collins (R-Maine) focused on law enforcement's role in assisting people who have addiction issues. "In Western Maine, a police chief is spearheading a program called Project Save Me," she said. "The idea is to encourage addicts to come to the police department, turn in their drugs and drug paraphernalia, and then get connected with a counselor who can get them on a treatment path. They won't be arrested ... Other towns in Maine are also testing this model."

Hearing witness Eric Spofford, CEO of Granite House, a substance abuse treatment facility in Derry, N.H., agreed that such efforts should be supported, and noted that the criminal justice system is one of the largest treatment centers for substance use disorders.

"The statistics are that 85% of incarcerated people have substance use disorders, and [it costs an] average of $48,000 to $52,000 a year to incarcerate them -- and there is almost no rehabilitation service for these folks getting out. If they're not in the process of recovery [when they're released], they'll behave and act in the same ways they always have."

Spofford, a former heroin addict who has been sober since 2006, said that while many people still switch from prescription opioids to heroin once they can no longer get the prescription drugs, some are now turning to fentanyl.

"This drug is so much more potent than heroin and far cheaper -- a good bulk 10 grams of heroin on the street is $650, but they're getting fentanyl for $150. It looks the same, smells the same, and they don't tell 'em the difference," he said. "In New Hampshire we've had a spike in overdose deaths, and it's directly related to fentanyl."

One contentious issue at the hearing was the current cap of 100 on the number of opioid-addicted patients for whom trained physicians can prescribe drug treatments such as buprenorphine and methadone. Sen. Orrin Hatch (R-Utah) noted that in August 2015, he joined Sen. Ed Markey (D-Mass.) and others in writing to Burwell to ask HHS to use its full authority to raise the cap, an idea that HHS has said it will consider.

Hearing witness Lena Wen, MD, health commissioner for the city of Baltimore, liked that idea. "There is no other medication for which there is a cap," she said, noting that buprenorphine and methadone are both considered first-line treatment for opioid addiction by the WHO and other medical groups. "I would take the cap off and encourage other prescribers -- nurse practitioners and others -- to be able to prescribe this medication."

She added that "Anecdotally, I have seen individuals come from [Maryland's] Eastern Shore and other states asking providers from Baltimore City to accept them" for medication-assisted addiction treatment, but the providers cannot do so because of the cap. However, she added, "It's important that medication-assisted treatment is only one part of treatment; psychotherapy also has to be a part, along with other resources."

Spofford disagreed with the idea of removing the cap. Earlier in the hearing, he explained that he was a proponent of abstinence-based treatment. "I and my industry peers believe we can be free from all mind-altering substances and don't need a crutch such as buprenorphine or methadone to stay away from heroin."

One thing that would be helpful in treating addicts would be standards of care that could be used by insurers to determine coverage for inpatient stays, said Spofford. "We'd see [for example] a 22-year-old heroin addict that has been an IV drug user for 3 or 4 years, and before he's able to receive inpatient treatment, the insurance company would say he needs to fail outpatient treatment first. I've seen people die from failing outpatient treatment."

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